title: Quality gaps and comparative effectiveness in lung cancer staging and diagnosis.
abstract: BACKGROUND
  Guidelines recommend mediastinal lymph node sampling as the first invasive test in patients with suspected lung cancer with mediastinal lymphadenopathy without distant metastases, but there are no comparative effectiveness studies on how test sequencing affects outcomes. The objective was to compare practice patterns and outcomes of diagnostic strategies in patients with lung cancer.
  
  
  METHODS
  The study included a retrospective cohort of 15,316 patients with lung cancer with regional spread without distant metastases in the Surveillance, Epidemiology, and End Results or Texas Cancer Registry Medicare-linked databases. If the first invasive test involved mediastinal sampling, patients were classified as receiving guideline-consistent care; otherwise, they were classified as receiving guideline-inconsistent care. We used propensity matching to compare the number of tests performed and multivariate logistic regression to compare the frequency of complications.
  
  
  RESULTS
  Twenty-one percent of patients had guideline-consistent diagnostic evaluations. Among patients with non-small cell lung cancer, 44% never had mediastinal sampling. Patients who had guideline-consistent care required fewer tests than those with guideline-inconsistent care (P &lt; .0001), including thoracotomies (49% vs 80%, P &lt; .001) and CT image-guided biopsies (9% vs 63%, P &lt; .001), although they had more transbronchial needle aspirations (37% vs 4%, P &lt; .001). The consequence was that patients with guideline-consistent care had fewer pneumothoraxes (4.8% vs 25.6%, P &lt; .0001), chest tubes (0.7% vs 4.9%, P &lt; .001), hemorrhages (5.4% vs 10.6%, P &lt; .001), and respiratory failure events (5.3% vs 10.5%, P &lt; .001).
  
  
  CONCLUSIONS
  Guideline-consistent care with mediastinal sampling first resulted in fewer tests and complications. We found three quality gaps: failure to sample the mediastinum first, failure to sample the mediastinum at all in patients with non-small cell lung cancer, and overuse of thoracotomy.
authors.affiliation: Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX. Electronic address: dost@mdanderson.org.
authors.forename: David E
authors.initials: DE
authors.lastname: Ost
authors.affiliation: Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Jiangong
authors.initials: J
authors.lastname: Niu
authors.affiliation: Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Linda S
authors.initials: LS
authors.lastname: Elting
authors.affiliation: Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Thomas A
authors.initials: TA
authors.lastname: Buchholz
authors.affiliation: Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Sharon H
authors.initials: SH
authors.lastname: Giordano
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002289:Carcinoma, Non-Small-Cell Lung / Q000401:mortality / Q000473:pathology*; D015331:Cohort Studies; D057186:Comparative Effectiveness Research; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D008175:Lung Neoplasms / Q000401:mortality / Q000473:pathology*; D008297:Male; D008482:Mediastinum / Q000473:pathology; D009367:Neoplasm Staging; D010818:Practice Patterns, Physicians' / Q000592:standards*; D011787:Quality of Health Care / Q000592:standards*; D012042:Registries; D012189:Retrospective Studies; D018426:SEER Program; D021701:Sentinel Lymph Node Biopsy; D013781:Texas; D014481:United States